Healthcare Provider Details

I. General information

NPI: 1114253853
Provider Name (Legal Business Name): MARY JEAN B. URSUA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2009
Last Update Date: 11/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 W PAPA AVE
KAHULUI HI
96732-2639
US

IV. Provider business mailing address

383 W PAPA AVE
KAHULUI HI
96732-2639
US

V. Phone/Fax

Practice location:
  • Phone: 808-877-0351
  • Fax: 808-877-0351
Mailing address:
  • Phone: 808-877-0351
  • Fax: 808-877-0351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberW03609234-01
License Number StateHI

VIII. Authorized Official

Name: MS. MARY JEAN BARBADO URSUA
Title or Position: LPN
Credential: CAREGIVER
Phone: 808-877-0351